Schedule Reg-1-O - Owner And Officer Information - Illinois Department Of Revenue
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Illinois Department of Revenue
Schedule REG-1-O
Owner and Officer Information
Attach to Form REG-1.
Business name: _________________________________________
FEIN: ______ - __________________
Contact for this schedule: __________________________________
SSN:
_________ - ______ - ____________
(Proprietorship only)
Phone: (______) ______ - ____________
Read this information first.
Complete this schedule if you need to identify more than provided for on Form REG-1, Step 2. See the list below to determine your specific
identification requirement. To identify more, attach a separate sheet using a similar format. Please print.
Proprietorship
=
Owner (and spouse if jointly owned).
Partnership
=
General partners only.
Corporation and S corp
=
Each officer.
Trust or estate
=
Each trustee or executor.
Governmental unit
=
You are only required to identify a contact person.
Not-for-profit organization
=
Each officer.
Limited liability company
=
Each manager and member.
Step 1: Identify your owners and officers who are individuals
Note: Social Security numbers are required to complete registration.
a
e
___________________________________ ___________________
___________________________________ ___________________
Legal name
Title
Legal name
Title
(____) _____ - ________
(____) _____ - ________
_______________________________
_______________________________
Home street address - No PO box
Phone
Home street address - No PO box
Phone
________________________________________________________
________________________________________________________
City
State
ZIP
City
State
ZIP
____ / ____ / ________
______-____-_________
____ / ____ / ________
______-____-_________
Social Security number
Social Security number
Date of birth
Date of birth
b
f
___________________________________ ___________________
___________________________________ ___________________
Legal name
Title
Legal name
Title
(____) _____ - ________
(____) _____ - ________
_______________________________
_______________________________
Home street address - No PO box
Phone
Home street address - No PO box
Phone
________________________________________________________
________________________________________________________
City
State
ZIP
City
State
ZIP
____ / ____ / ________
______-____-_________
____ / ____ / ________
______-____-_________
Social Security number
Social Security number
Date of birth
Date of birth
c
g
___________________________________ ___________________
___________________________________ ___________________
Legal name
Title
Legal name
Title
(____) _____ - ________
(____) _____ - ________
_______________________________
_______________________________
Home street address - No PO box
Home street address - No PO box
Phone
Phone
________________________________________________________
________________________________________________________
City
State
ZIP
City
State
ZIP
____ / ____ / ________
______-____-_________
____ / ____ / ________
______-____-_________
Social Security number
Social Security number
Date of birth
Date of birth
d
h
___________________________________ ___________________
___________________________________ ___________________
Legal name
Title
Legal name
Title
(____) _____ - ________
(____) _____ - ________
_______________________________
_______________________________
Home street address - No PO box
Phone
Home street address - No PO box
Phone
________________________________________________________
________________________________________________________
City
State
ZIP
City
State
ZIP
____ / ____ / ________
______-____-_________
____ / ____ / ________
______-____-_________
Social Security number
Social Security number
Date of birth
Date of birth
*045401110*
Schedule REG-1-O (R-04/10)
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